Advanced Fibrosis in NASH: Patient Management

Recommendations for monitoring and managing patients with advanced fibrosis caused by nonalcoholic steatohepatitis to reduce disease burden and prevent progression.


Viviana Figueroa Diaz, MD: Patients with advanced fibrosis should be monitored no more than every 6 months. Check in with the patient, see how they’re doing with their lifestyle modifications, make sure that if they have diabetes that their diabetes is under control. If they have uncontrolled diabetes, you should probably be following up even earlier—maybe every 3 months. It really depends on what’s going on in regard to risk factors for advanced fibrosis.

Norman Sussman, MD: Are there other things you need to know about fatty liver disease? The answer is yes. Fatty liver disease is a manifestation of a condition we call metabolic syndrome. Metabolic syndrome has a number of features, including a certain type of obesity, high blood sugar, high blood pressure, abnormal blood lipids, high cholesterol, low HDL [high-density lipoprotein], or high triglycerides.

When we see a patient with NASH [nonalcoholic steatohepatitis], we have to realize that they have a multisystem disease. In addition to liver problems, they are susceptible to cardiovascular disease, especially strokes and heart attacks, and they have an increased risk of all kinds of cancers, including liver cancer.

Mazen Noureddin, MD: NAFLD [nonalcoholic fatty liver disease] is an epidemic, and it is very costly to the healthcare system as well as to the patient’s well-being. A publication showed that the number of NAFLD patients in 2015 in the United States was around 83 million. That number will increase significantly by 2030. The number of patients with cirrhosis due to NASH is expected to increase from around 3 million, in 2015, to 7 million, in 2030. So this phenomenon is really an epidemic. In addition, hepatocellular carcinoma due to nonalcoholic fatty liver disease has been increasing in incidence and prevalence around the world, which is very costly to the health system, in treating and managing it.

We have published data showing that nonalcoholic fatty liver disease is the most common cause of liver transplant in women these days. Liver transplant is very costly, and this disease has no treatment so far. Therefore, recognizing it, stopping it, and treating patients and avoiding progression will be timely to get rid of this disease.

One of the big areas in the disease is halting progression. For instance, when you arrive to F3, or advanced fibrosis, it is crucial not to get to cirrhosis. Cirrhosis has been shown to be associated with the highest risk of morbidity and mortality. If you can avoid that, you’ll avoid the high cost of liver transplant: hepatocellular carcinoma. More important, you will save the patient from many life-threatening conditions. Therefore, halting advanced fibrosis and reversing it—both of them are very much needed.

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